The broader picTure

The role of social carecraig Morgan

AbstractSocial care is a generic term that refers to all those services provided to

adults requiring assistance with aspects of daily living as a consequence

of illness or disability. This contribution explores the role of social care

in relation to mental illness. Such services have taken on an increasingly

important role in mental healthcare as the locus of care has shifted from

institutional to community settings. While often being seen as the ‘poor re-

lation’ to healthcare, social care services have the potential to significantly

improve sufferers’ quality of life, promote social inclusion and recovery, and

prevent relapse from a range of mental illnesses, including depression and

schizophrenia. however, there remain a number of barriers to the success-

ful integration of social and healthcare that need to be overcome if the

ideal of multidisciplinary care for the mentally ill is to be realized.

Keywords depression; multidisciplinary working; quality of life;

schizophrenia; social care; social work

Social care is a generic term embracing all those services pro-vided to ‘adults who require assistance with aspects of daily living as a result of disability, illness or ageing’.1 All forms of mental illness have an impact – to a greater or lesser degree – on daily living, often impairing the capacity of sufferers to attend to domestic chores, sustain employment and develop and maintain supportive relationships. As the locus of mental healthcare has moved from long-stay institutions to the community, the impor-tance of social care services in providing practical and emotional support to enable people with mental health problems to func-tion successfully in community settings has grown.

This contribution describes the range of social care services available relating to mental health, discusses the value of social care services in this field and considers the often problematic relationship between healthcare (psychiatry) and social care.

The range of social care services

Agencies and activitiesSocial care workers are employed by a range of agencies, both voluntary and statutory, and in a variety of settings, including:

Craig Morgan MSc PhD is MRC Special Research Fellow in Health Services

Research and Non-Clinical Lecturer at the Institute of Psychiatry,

London, UK. His research interests include ethnic variations in the

use of mental health services, and social influences on the onset and

course of severe mental illness. Conflicts of interest: none declared.

pSYchiaTrY 6:8 34

• hostels • day-care centres • community mental health teams (CMHTs) • patients’ own homes or localities.A wide assortment of tasks are undertaken, ranging from those that are relatively structured, such as welfare and housing advice and advocacy, to those that are more nebulous and unstructured, such as support, counselling and befriending. There is some overlap with healthcare professionals such as community psy-chiatric nurses, who often provide informal support and coun-selling. The diversity of tasks is reflected in the many job titles under which social care workers are employed: support worker, project worker, residential social worker, day-care assistant and so on. Within this broad group there are considerable variations in levels of training and responsibility, and many work part-time or on a voluntary basis. The majority are unqualified or have basic qualifications in social care, and only a minority are profes-sionally qualified social workers.

Social workQualified mental health social workers are usually employed by local authorities and attached or formally seconded to multidisci-plinary mental health teams, based either in community or hos-pital settings. While qualified social workers are often engaged in providing the services outlined above, they have additional responsibilities and duties. Key among these are: • care coordinator responsibilities under the revised Care

Programme Approach (CPA) • the preparation of social circumstances reports for mental

health review tribunals • liaising with and supporting families and carers • approved social worker (ASW) duties under the Mental Health

Act 1983.Under provisions in the Mental Health Bill, currently before par-liament, ASW duties will be undertaken by Approved Mental Health Professionals, which in effect opens the role to a wider range of professionals.

Throughout the 1960s and 1970s, social work professionals were often engaged in directly providing therapeutic interven-tions, based on psychoanalytic or behavioural theories of dis-order and change. This role has diminished over the past two

• The publication of the Social exclusion unit’s report on social exclusion and mental illness has highlighted the importance of addressing the social needs of sufferers

• approved social worker (aSW) duties are no longer to be performed solely by appropriately qualified social workers, under provisions in the Mental health bill to amend the 1983 Mental health act (still under review)

• Social workers are increasingly being formally seconded to mental health trusts to facilitate integrated working. The impact of this remains to be seen

What’s new?

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The broader picTure

decades, primarily as a consequence of the introduction of a purchaser–provider split in the organization of health and social services under the NHS and Community Care Act 1990. Conse-quently, local authority social workers have been progressively more engaged in devising and purchasing packages of care, with the provider role – particularly the provision of social care – being increasingly fulfilled by the growing voluntary sector. The range of agencies and staff involved in providing social care for people with mental health problems is illustrated in Table 1.

The value of social care

The provision of mental healthcare in the UK is dominated by psychiatry and the overwhelming proportion of government spending on mental health is on health services, particularly in-patient care; social care is the ‘poor relation’ and is often under-valued. However, the potential benefits of social care services can be considered under two headings: social inclusion and qual-ity of life; and therapeutic benefits.

Quality-of-life benefitsThe social consequences of all forms of mental illness can be far-reaching. In 2004 the Social Exclusion Unit published a major report documenting the extent of social disadvantage and dis-crimination faced by those with a mental illness, and set a series

The range of social care services

Agency Staff Services

Social Services Social workers community mental

health teams

care managers residential care

other social care

workers

day centres

Supported housing

advice, information

and advocacy

Voluntary services

(inc. user-led and

self-help groups)

paid staff counselling

Volunteers befriending

users, carers,

friends and families

housing/supported

housing

residential care

day centres

advice/information

and advocacy

care and support

employment schemes

Services for minority

groups (e.g. black,

lesbian and gay)

crisis services

Self-help

Table 1

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of targets for promoting social inclusion for the mentally ill.2 While the focus of psychiatric services is often on presenting symptoms – with medication a first line of treatment – research indicates that for many sufferers the effects of mental illness on social functioning and relationships are of primary importance. Addressing problems in these domains is a key characteristic of social care services, and it is clear that such services have a poten-tial role in promoting social reintegration of those suffering from a mental illness.3,4 A further key concept in evaluating the impact of such interventions is that of quality of life. This has become an increasingly important notion in mental health services research over the past decade, and has the value of placing the concerns and views of service users at the centre of outcome research. When their views are heard it is clear that services aimed at ameliorating financial, housing and relationship difficulties are among the most popular.5 However, there are deficiencies in the availability and quality of such services, suggesting that social care services need to be given a higher priority.

Therapeutic benefitsSocial care interventions also have an important therapeutic role in improving quality of life and social functioning, and working along-side healthcare services to promote recovery and reduce relapse rates for a range of mental illnesses. This can be illustrated briefly in relation to two major disorders, depression and schizophrenia.

Depression: the work of George Brown, Tirril Harris and col-leagues has firmly established that significant life events and ongoing difficulties are of aetiological importance in depression, particularly those events and difficulties that are humiliating, dis-empowering and/or isolating (see Harris6). This programme of research has also identified a number of protective factors which serve to reduce the risk of depression or promote recovery. Prom-inent among these are the value of supportive social networks in reducing risk, and the importance of fresh-start events, such as beginning a new job after a long period of unemployment, in promoting recovery, events that seem ‘to embody the promise of new hope against a background of deprivation’.6

Such insights have important implications. Interventions designed to support sufferers in, for example, gaining employment or in establishing new social networks, have the potential not only to improve social functioning but to promote recovery and prevent relapse. Where social support is lacking, social care workers can provide this directly. Brown, Harris and colleagues investigated the efficacy of a volunteer befriending service for a sample of chroni-cally depressed women in London.7 They found that this service contributed substantially to remission. Unfortunately, there has been only limited well-designed research into the efficacy of social care interventions, but these findings support the view that such interventions may be of substantial therapeutic value.

Schizophrenia: there is significant research suggesting that social factors are important in mediating the course of schizophrenia. This is most evident in the consistent finding that high levels of expressed emotion among families, mediated by medication use and amount of face-to-face contact, are strongly predictive of relapse.8 Following from this, a number of family-focused interventions designed to reduce levels of expressed emotion (a key component of each being practical and emotional support)

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The broader picTure

have been found to be effective in reducing relapse rates.9 Early research by Wing and Brown showed that an under-stimulating environment could exacerbate the negative symptoms of schizo-phrenia,10 and there are suggestions that paid employment may promote recovery from schizophrenia and foster reintegration into society.11,12 Once again, the potential therapeutic implications for social care interventions, which provide stimulating activities and assist sufferers in gaining employment, are evident.13

The interface between health and social care

Social care services for people with mental health problems have always operated at the interface with health services. The relation-ship between the two has often been problematic, however, with substantial barriers to successful interdisciplinary working. The need for integrated health and social care services has been a recurrent theme over many years, and since the early 1990s there has been an increasing emphasis on multidisciplinary working in mental health. Indeed, multidisciplinary teams based in institutional or community settings now form the cornerstone of mental healthcare. However, difficulties remain and two general and longstanding barriers to successful inter-agency working are particularly noteworthy.

Organizational separation: the division between health and social care is institutionalized in the structural split between the NHS and local authority services. In the main, social workers are employed by the local authority, and while this allows a measure of independence that can work in the sufferer’s favour, it intro-duces a structural barrier to integrated working and has been a source of tension and confusion owing to different organizational priorities and practices. This is perhaps best illustrated by the confusion caused by the operation of two systems of care plan-ning and management throughout the 1990s, one health-led (the CPA), the other local authority-led (care management). In recent years there have been attempts to promote integrated working, with social workers being either formally seconded to, or directly employed by, mental health trusts under provisions of the 1999 Health Act. The impact of this remains to be seen.

Interdisciplinary tensions: the structural separation of health and social care mirrors differences in perspectives among those working in mental health which further hinder integration. At the heart of the ideal of multidisciplinary working is the notion that mental illness (in all its forms) creates a complex set of needs that, crucially, can be addressed only through the intervention of a team which encompasses a range of perspectives, skills and knowledge. In reality, different perspectives have been a source of tension and conflict. A study by Colombo et al. provides a good illustration of how implicit models of mental illness held by different mental health professionals can hinder successful interdisciplinary collaboration.14

Conclusion

Social care is an important component of the range of services for people with mental health problems. The services subsumed under this broad heading are varied, offering a diverse range of interven-tions that are valuable both in ameliorating the social consequences of mental illness and in reducing relapse rates and promoting

pSYchiaTrY 6:8 34

recovery. There remain, however, problems with integrating social and healthcare to provide the kind of integrated model of care that has long been envisaged. Amidst the host of recent government initiatives relating to mental healthcare, there have been efforts to promote better inter-agency working, the revised CPA being one example. As with all these initiatives, however, their impact on quality of care and patient outcomes remains to be seen. ◆

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fuRTheR ReAding

davies M, ed. The blackwell encyclopaedia of social work. oxford:

blackwell, 2000.

(A useful reference work with brief contributions relating to all

major aspects of social work and social care.)

harris T. recent developments in understanding the psychosocial

aspects of depression. in: Lader Mh, cowen pJ, eds. depression.

oxford: oxford university press, 2001.

(A useful review of recent research relating to the psychosocial

aspects of depression.)

Warner r. The environment of schizophrenia: innovations in practice,

policy and communications. London: routledge, 2000.

(A short and practical review of the environmental influences on

schizophrenia.)

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